Healthcare Provider Details

I. General information

NPI: 1710561964
Provider Name (Legal Business Name): RANDALL CONAWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 HARMON PL
MINNEAPOLIS MN
55403-2043
US

IV. Provider business mailing address

1201 HARMON PL
MINNEAPOLIS MN
55403-2043
US

V. Phone/Fax

Practice location:
  • Phone: 612-450-1379
  • Fax:
Mailing address:
  • Phone: 612-450-1379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number29043
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: